- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia 16150, Kubang Kerian, Kelantan, Malaysia
Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia 16150, Kubang Kerian, Kelantan, Malaysia
DOI:10.4103/2152-7806.118492Copyright: © 2013 Idris Z This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Idris Z, Nandrajog P, Abdullah JM, Ghani RI, Idris B. Neuronavigation-guided endoscopic and hodotopic approach to an arachnoid cyst. Surg Neurol Int 19-Sep-2013;4:120
How to cite this URL: Idris Z, Nandrajog P, Abdullah JM, Ghani RI, Idris B. Neuronavigation-guided endoscopic and hodotopic approach to an arachnoid cyst. Surg Neurol Int 19-Sep-2013;4:120. Available from: http://sni.wpengine.com/surgicalint_articles/neuronavigation-guided-endoscopic-and-hodotopic-approach-to-an-arachnoid-cyst/
Background:Arachnoid cysts are intraarachnoid benign cystic lesions filled with cerebrospinal fluid and should be treated without incurring further morbidity to the patients.
Case Description:The authors present a case of a 68-year-old elderly female with a large right fronto-parieto-temporal arachnoid cyst who has been suffering from mild left hemiparesis for the past 4 years and presented with sudden onset of seizures. The 3 Tesla MR system with diffusion tensor imaging (DTI) and MR tractography of the brain showed a large right fronto-parieto-temporal cystic lesion measuring 7 × 5 × 5 cm with a midline shift of 1 cm, suggestive of an arachnoid cyst with surrounding ipsilateral white matter projection pathways and inferior occipito-frontal fasciculus or inferior longitudinal white matter tracts. The cyst was successfully treated with neuronavigation-guided endoscopic and hodotopical approach to fenestrate the arachnoid cyst into the sylvian cistern, avoiding inadvertent injury to major white matter tracts portrayed by DTI. Postoperatively, a repeated computed tomography (CT) scan of the brain revealed a smaller arachnoid cyst with correction of the midline shift. The patient was weaned off from the ventilator and her hemiplegia improved gradually.
Conclusion:This case report emphasizes the value of neuronavigation-guided endoscopic and hodotopic approach to fenestrate the intra-axial arachnoid cyst.
Keywords: Arachnoid cyst, endoscopy, hodotopy, neuronavigation, tractography
Symptomatic arachnoid cysts should be treated without incurring further morbidity to the patients. Advances in neuroimaging from sectional anatomy depicted by magnetic resonance imaging (MRI) of the brain to connectional anatomy represented by diffusion tensor imaging (DTI) with tractography has revolutionized surgical strategies in treating brain lesions. DTI and hodotopic approach have mostly been applied in neurosurgery for craniotomy and brain tumor surgery.[
A 68-year-old elderly female who has been suffering from mild left hemiparesis for the past 4 years presented to our hospital with history of sudden onset of left sided tonic-clonic seizures that became generalized. She was intubated because of airway compromise. Physical examination prior to intubation disclosed that the patient had left hemiplegia and hyperreflexia on the left limbs with extensor plantar reflex. The cranial nerves and systemic examination were normal. The computed tomography (CT) scan of the brain showed a large right fronto-parieto-temporal cystic lesion measuring 7 × 5 × 5 cm with a midline shift of 1 cm, suggestive of an arachnoid cyst [Figure
(a-d) An image guided endoscopic fenestration of the cyst. (a) The site of interest was identified using neuronavigation. (b) The intraoperative endoscopic image of forceps entering the parenchyma to fenestrate the cyst to the sylviann cistern. (c) Identification of sylviann cistern using neuronavigation and (d) Sylviann cistern
Postoperatively, a repeated CT scan of the brain revealed a smaller arachnoid cyst with correction of the midline shift [Figure
Arachnoid cysts are intraarachnoid benign cystic lesion filled with cerebrospinal fluid. It is derived from developmental abnormalities during growth. Some suggested it result from traumatic injury of arachnoid layer.[
Location and content of the cyst and the relationship to neural and vascular structure are best demonstrated on T1 and T2 images. DTI is an emerging and noninvasive MRI-based technique that can demonstrate white matter anatomy by measuring the directional anisotropy of water.[
De Benedictis and Duffau have studied the brain white matter anatomy and listed out some of important white matter tracts and their connections.[
The management of arachnoid cyst remains controversial. At the moment, there are no class I or class II studies on management of arachnoid cyst. Generally, surgery is reserved for symptomatic patient with neurological deficit regardless of the age of the patient. Objective of surgery is to reduce intracranial pressure as a result from pressure effect of the arachnoid cyst. Options of surgical techniques are craniotomy and cyst wall excision,[
Hodotopic endoscopic approach to the brain is possible nowadays by using noninvasive MRI technique called DTI with tractography. This noninvasive imaging technology has helped us to plan an alternative endoscopic approach to fenestrate the symptomatic large cerebral convexity arachnoid cyst to the pulsating sylviann cistern.
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